Phys Med Rehabil Clin N Am

17 (2006) 789801

Common Musculoskeletal Problems

in the Performing Artist
Pamela A. Hansen, MD*, Kristi Reed, MD
Department of Physical Medicine and Rehabilitation, University of Utah,
768 E 4th Avenue, Salt Lake City, UT 84103, USA

In this chapter we examine some of the musculoskeletal injuries unique to

musicians and dancers. The cornerstone of treatment in this specialized pa-
tient population is the understanding that the injuries these artists sustain
occur in the context of a distinctive lifestyle. This lifestyle demands extreme
physical and emotional stressors that are far outside the normal range of
standard occupations and even most competitive sports. Understanding
and treating all aspects of the performer requires a highly specialized inter-
disciplinary team approach that appreciates all of the conditions that govern
these patients lives.

Musculoskeletal injury in the musician

Instrumental musicians are a special risk group for musculoskeletal
injuries. A large percentage of them have problems related to playing their
instruments using incorrect posture, nonergonomic technique, excessive
force, overuse, and insucient rest, which may in turn result in musculoskel-
etal injury. These injuries can be devastating, leading to pain, which can be
artistically and professionally limiting, or even career ending, with deleteri-
ous eects on the musicians physical, emotional, and nancial well-being.
This chapter reviews risk factors for musculoskeletal injuries in musicians
and the importance of understanding the whole person. Preventative strat-
egies are introduced. Proper evaluation of musicians who have musculoskel-
etal complaints are addressed, and discussion of specic diagnosis and
treatment options commonly seen in musicians are done using a problem-
oriented approach.
Routine daily activities place demands on the body that may contribute
to the development of a musculoskeletal injury. The large number of hours

* Corresponding author.
E-mail address: Pamela.Hansen@hsc.utah.edu (P.A. Hansen).

1047-9651/06/$ - see front matter 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.pmr.2006.08.001 pmr.theclinics.com
790 HANSEN & REED

musicians spend practicing, rehearsing, and performing predispose them to

musculoskeletal injury; multiple studies have found that anywhere from
50% to 80% of musicians experience physical problems. Risk seems to be
greatest in string players and keyboardists, likely due to the postural de-
mands of these instruments. These instruments require constant rapid move-
ment for prolonged periods at forces that may exceed the bodys capabilities
to repair without adequate recovery time. Signs and symptoms of injury
may appear suddenly or they may develop gradually over weeks to months.
Complaints often include pain, weakness, reduced range of motion, numb-
ness, tingling, or loss of muscular control, which interferes with their play-
ing. Pain often results in loss of speed, volume, or control making dicult
pieces impossible to play. Symptoms may not always be as problematic dur-
ing the causative, aggravating activity as they are after playing. Symptoms
often progress to being painful during the activity and become more dicult
to manage if treatment is not initiated early. As with any musculoskeletal
injury model, prevention ideal through controlling the risk factors and rec-
ognizing and responding to early signs and symptoms. Unfortunately, it is
common for dedicated performers to work through pain until they can no
longer perform. At this late stage, the likelihood of full recovery diminishes,
and the treatment process is more complex and disruptive to daily life.
Several risk factors may increase musculoskeletal injury in performing
artists. Understanding these risk factors and nding ways to minimize
them is the most eective way to prevent frustrating and potentially ca-
reer-ending eects of musculoskeletal injury. For performers, the greatest
risk of musculoskeletal injury occurs when changing a technique or using
a new instrument and with prolonged playing with inadequate rest such
as when preparing for a performance or perfecting a new, technically di-
cult piece. Risk factors can be broken down into environmental factors,
physical demands, and personal characteristics. Environmental risk factors
include cold temperature, conned space or layout of space, equipment, sur-
faces, and lighting. Physical demands include awkward postures, forceful
exertion, repetition, long-duration activities with inadequate rest, and vibra-
tion. Personal characteristics include an individuals posture, strength, ex-
ibility, endurance and comorbid health conditions. Poor nutritional status
and psychological stress, which often accompany a challenging schedule,
may also relate to injury risk or hinder healing.
Environmental risk factors may include playing in cool temperatures, in-
adequate lighting, poor instrument t, inadequately maintained instru-
ments, and improper surrounding environment. Cold temperatures reduce
blood ow to the ngers and arms and can slow nerve conductions in the
extremities. Inadequate lighting can inuence a musicians ability to read
music, resulting in altered posture and eyestrain. Selecting an environment
that is properly heated and well lit is ideal, but not always possible. When
the environment is not optimal, the musician should wear adequate clothing
to keep the entire body warm to maintain adequate blood ow to the
 MUSCULOSKELETAL PROBLEMS IN THE PERFORMING ARTIST 791

extremities. Gloves or ngerless gloves may help keep the hands warm.
Warming the hands before playing is important. In a poorly lit environment,
the use of portable lamps or battery-powered clip lights to illuminate music
can be helpful. Changing instruments presents a situation in which there is
a sudden change in physical demands and a resultant increase in the risk
of musculoskeletal injury. Playing poorly maintained or poorly designed
instruments can require greater eort or force than playing similar, well-
maintained instruments. One common example of this would be wind in-
struments with leaky valves or pads and string instruments with bridges
that are too high and require greater eort to play. Piano with excessive
dead space at the tops of the keys will require more force to obtain volume.
Choosing quality instruments and maintaining their proper working condi-
tion will assist in preventing musculoskeletal injury. Selecting an instrument
that properly ts will assist the musician in adopting a reasonable playing
posture without the need to adapt for excessive reaches or awkward hand
and nger postures.
It is important to consider the surrounding environment, including chairs,
music stands, and instrument stands to support the static weight of the in-
strument, which can have a profound inuence on playing posture. Chairs
should be at a height that allows the musicians feet to sit at on the ground
with the knees at a 90 angle. Chair cushions or footrests can accommodate
alignment if a chair is an inappropriate height and not adjustable. Position-
ing of the music stand should place the top of the sheet music at or just below
eye level. In addition to these general categories of risk factors, each musical
instrument is associated with a unique set of injuries related to the physical
and postural demands of playing that specic instrument. Evaluation and
treatment as well as risk factor recognition and modication must therefore
be musician and instrument specic. With such complex interplay, a multi-
disciplinary approach can serve this special patient population.

Overuse syndrome
Overuse syndrome or occupational overuse syndrome is a poorly dened
and often incorrectly used term to dene a constellation of symptoms of
pain associated with activity and no specic diagnosis. The predominant
feature of this syndrome is pain, and it is believed to be the most prevalent
medical problem aecting musicians. Overuse syndrome is present in up to
50% of professional symphony orchestra musicians [1] and it accounts for
50% to 80% of consultations [2]. There may also be weakness or loss of
ne motor control, but sensory symptoms are absent. Symptoms often de-
velop after a change from the usual routine and may only be present just
after or during performance. Any uctuation in practice schedule involving
a more dicult piece, prolonged playing times, inadequate rest periods, or
touring can bring about an exacerbation. Factors known to contribute in-
clude physical disproportion between the instrument and the musician,
792 HANSEN & REED

poor posture, fatigue, excessive nger angulation, and biomechanical pre-

conditions such as hypermobility or hypomobility of critical joints [3].
The common underlying pathology involves the tissues being stressed be-
yond their physiological limits; however, there is much debate as to the
pathophysiology of this syndrome. Some investigators suggest that patho-
logic changes to peripheral tissues are involved, whereas others have pro-
posed that the basis of symptoms is either fatigue or psychological
pathology. There is certainly much debate as to the etiology and all of the
contributing factors that make up this clinical picture. Currently, theories
center on this entity as a protective mechanism occurring by some yet
unknown physiologic process. When tissues are stressed, an unpleasant
reaction is then set in motion that serves to limit the oending activity
and therefore relieve the physiological stress [4]. In many cases, overuse syn-
drome is misdiagnosed bursitis, tendonitis, or other inammatory condi-
tions that can be shown to bring about histologic change. Investigations
thus far have not shown overuse syndrome to bring about any of the histo-
pathologic changes seen in inammatory conditions.
Evaluation of the professional musician suspected of having overuse syn-
drome requires a detailed systematic observation of the musician and his in-
teraction with his instrument. The patient should be undressed suciently
for examination and should be assessed briey for overall habitus, tness,
and posture. Any underlying disease should be noted. A full musculoskeletal
examination should involve assessment of range of motion and strength of
all joints of the upper limbs as well as the neck, shoulders, and spine. Any
discomfort or reproduction of usual symptoms will aid in narrowing
down the pain generator. Joints should also be assessed for hypermobility
as well as hypomobility. Joint deformity as well as callous formation can
be an indicator of poor technique. A full neurologic examination should
include signs of muscle atrophy indicating possible neuropathy as well as
sensation and reexes. The patient should be examined playing their instru-
ment in a manor that most closely resembles their usual playing style. With
the musician performing, one may easily evaluate tension, pressure, and an-
gulations of the painful area as well as all adjoining segments. Observations
should also be made after a prolonged period of practice so that a compar-
ison may be made as the musician fatigues. This can be accomplished easily
with video taped sessions if observation is not practical in the oce setting.
A specically trained physical or occupational therapist often can assist in
biomechanical evaluation as well.
Treatment of overuse syndrome centers on relative rest. Because musi-
cians have high anxiety associated with job uncertainty and extreme pres-
sure to maintain standards of almost unattainable excellence, rest often is
met with great resistance. In an attempt to have as little impact on career
as possible, it is often helpful to involve coaches, conductors, music teachers,
or managers. These professionals can advise realistic plans of rest periods
and practice schedules that will help ensure patient compliance and overall
 MUSCULOSKELETAL PROBLEMS IN THE PERFORMING ARTIST 793

treatment success. Investigators have reported more than 80% success rates
of return to normal playing schedules [5] with relative rest and slow gradual
rehabilitation. A good general guideline for treatment starts with ergonomic
modication as well as instrument modication when possible. Straps can
be used to help support the weight of a heavy instrument, keys on woodwind
instruments may be altered for ease of ngering, and chair height and seat-
ing can be adjusted. The actual size of the instrument may be adjusted and
can have a large impact on biomechanics. In some cases, a change may be
benecial. Blum and Ahlers [6] found a relationship between the size of
the viola and shoulder problems. There is some variation in violas, and vi-
olists playing instruments greater than 40 cm in length are more likely to
have shoulder pain. After ergonomic and postural adjustments, a detailed
program of rest should be outlined and agreed on by musician, music
teacher or conductor, and physician. Musical pieces that are less technically
demanding should be used for practice sessions, and length of practice ses-
sions and performances should be extended very gradually. Rest times vary
by degree of injury, and the amount of rest needed can vary from days to
months. When play resumes, optimizing proper warm up, relaxation train-
ing, hydration, proper diet, and physical conditioning can all aid in rehabil-
itation and injury avoidance. Physical therapy and occupational therapy
with modalities as needed to get the patient through the acute phase may
consist of heat, ice, transcutaneous electrical nerve stimulation, soft tissue
mobilization, and ultrasound scan. Splinting may be used to decrease static
or dynamic forces or to transfer force to adjacent structures; however,
splinting actually may cause technical diculties with performance and
may actually cause injury to other unaected joints. Nonsteroidal anti-in-
ammatory medications are often used; however, there is controversy con-
cerning this practice as overuse syndrome is considered a noninammatory
condition. Local injections of steroids have been used with varied success.
Proper diagnosis and early management of overuse syndrome is not only
essential in preventing loss of practice and performance time, but there is
some evidence that there may be an association between overuse syndrome,
complex regional pain syndrome (formerly, reex sympathetic dystrophy),
and focal dystonia. Lockwood and Lindsay [7] have reported an association
between overuse syndrome, reex sympathetic dystrophy (RSD), and focal
dystonia. Their data support the early diagnosis of RSD because they be-
lieve that it may be the sensory analog of dystonia.

Focal motor dystonias

One of the more rare but perhaps most debilitating problems for the
instrumentalist is focal motor dystonia. This is an insidious problem that
develops over many years [8]. Focal motor dystonia is characterized best
by painless spasm and involuntary movements in the aected limb. These
movements are almost always aggravated by voluntary movement and
794 HANSEN & REED

may be apparent only during playing but in advanced cases may occur at
rest [9]. In one series, Newmark and Hochberg looked at painless, uncoor-
dinated movements in 57 musicians [10]. Their data suggest that the most
commonly aected musicians were keyboard players (n 35), followed
by string players (n 13), and woodwind players (n 9). Their data also
reect that involuntary exion of the fourth and fth digit is the most com-
mon dystonia, with the right hand being more aected than the left. This
condition has also been found to be more common in men with average
age of onset at 38 years [11].
To date, the pathogenesis of focal motor dystonia is unknown, and there
is no proven denitive treatment. Several theories as to etiology favor a cen-
tral origin that is a function of excessive motor cortical excitability with
poor cortical sensory processing and mediation from the basal ganglia
[11]; still others suggest associations with multiple types of prior injury
[7,10,12]. Some patients report that by producing sensory input such as
touching the skin, or proprioreceptive input such as a small change in posi-
tion, they can achieve temporary relief [9]. Permanent resolution of symp-
toms, however, is yet elusive, and possibly the most appropriate
intervention is referral for psychological counseling because this condition
often is career ending. Treatments tried without great success include
steroids (both oral and local injections), prolonged rest, physical therapy,
botulinum toxin, biofeedback, tricyclic antidepressant medications, immobi-
lization, bromocryptine, and surgery. The importance of diagnosis cannot
be understated, because this devastating condition may have an underlying
biochemical, metabolic, genetic or anatomic etiologies that may benet from
more conventional treatments aimed at the specic condition. This has been
found to be the case in up to 25% of the documented cases [13]. Appropriate
diagnosis can spare the patient time, money, and often painful treatments
that will most probably have limited success [14].

Osteoarthritis
Osteoarthritis, although a common condition in the general population,
takes on special signicance in the musical performer. Musicians depend on
their bodies and specically their hands for their livelihood. A typical pro-
fessional musician has started his career at the age of 5 to 10 years, and
many instrumentalists have full-time schedules well into their 70s [15]. Be-
cause osteoarthritis is the most common type of arthritis and increases
with advancing age, it is commonly seen in the aging musician. The main
complaint of the arthritic patient is pain, but joint stiness and loss of range
of motion are thought to be the most detrimental. The joints most com-
monly aected in the general population are the metacarpalphalangeal
(MCP), distal interphalangeal (DIP), and carpometacarpal (CMC) joints
of the hands, spine, hips, and knees. Data reporting as to whether musicians
have a higher rate of degenerative arthritis in the hands and spine are sparse;
 MUSCULOSKELETAL PROBLEMS IN THE PERFORMING ARTIST 795

however, one might deduce that years of repetitive motion against static and
dynamic stressors would elevate the incidence in this group.
Careful workup and diagnosis to rule out specic inammatory condi-
tions such as DeQuervains tenosynovitis, overuse syndrome, and other
rheumatologic conditions is warranted because treatment strategies dier.
Signs and symptoms of osteoarthritis include dull aching pain that increases
with playing and is relieved by rest, joint stiness for less than 30 minutes,
joint instability, and crepitus on range of motion. Patients may also report
joint gelling which is perceived as a stiness lasting short periods that dis-
sipates after initial range of motion. Specic joint involvement includes spur
formation at the DIP joints (Heberdens nodes) and at the PIP joints (Bou-
chards nodes) as well as the rst CMC joint. Radiographic ndings include
asymmetric narrowing of the joint space, subchondral bony sclerosis, osteo-
phyte formation, and osseous cysts. It should be noted that no erosive
changes should be seen. Marginal or central erosions are more consistent
with rheumatoid arthritis.
Treatment is designed to protect the aected joint, alleviate painful symp-
toms, and restore range of motion. Once damaging playing techniques are
recognized, they must be changed if long-term joint health is to be main-
tained. Prompt treatment of tendonitis and other inammatory conditions
prevents misuse of the joint and subsequent alterations in biomechanical
forces. Splints may be used for relative rest and for joint instability; how-
ever, immobility that is prolonged causes demineralization of bone and mus-
cle atrophy, whereas exercise has positive eects on collagen deposition
tendon strength. There is a thin line between use and abuse in the osteoar-
thritic joint that the patient will ultimately have to balance. Musicians may
be taught to play in joint midrange to aid in joint preservation. This position
gives optimal balance between muscle stabilizers and active movers [16].
Patients should also be educated in proper warm-up techniques and may re-
quire external warming to alleviate stiness before performances. Medica-
tions include, acetaminophen, nonsteroidal anti-inammatory drugs, COX
II inhibitors, and in rare cases narcotics. Data on glucosamine and chon-
droitin Sulfate are inconclusive at this point, and formulations in the United
States are not regulated by the US Food and Drug Administration or stan-
dardized. In acute air ups, intra-articular steroid injections may be used. In
rare cases, surgical intervention including joint fusion and replacement may
alleviate symptoms and still allow the technical level of performance desired.

Joint hypermobility
Joint hypermobility can be associated with connective tissue disorders
such as Marfans or Ehlers-Danlos syndrome or can be seen in isolation
and identied as benign hypermobility. As in the general population, musi-
cians often experience laxity at one or more joints and it may be present on
examination of a painful or unstable joint. The question then is: is this
796 HANSEN & REED

pathologic? Is joint hypermobility an asset or a liability for instrumentalists?

There is much debate on this subject. Studies such as the one performed by
Larsson and colleagues [17] reported that based on observations of 660 mu-
sicians at music school, only 5% of the 96 musicians with hypermobility at
the wrist reported pain and stiness compared with the 18% of all other mu-
sicians. An opposing set of data from Brandfonbrener [18] based on studies
of 393 musicians with hand and arm pain, found a prevalence of 19% joint
laxity in her series suggesting laxity as a signicant factor predisposing
players to injury. Even with the contradictory evidence on hypermobility
as a whole, it is clear that on an individual basis, excess joint laxity can
be pathologic. Hypermobility can lead to instability of the loaded joint
and, in turn, lead to the development of traumatic synovitis in instrumental-
ists. Hypermobility can also lead to digital nerve compression, and hyperex-
tensibility of the wrist and elbow may contribute to neuropathy at these
sights by exacerbating traction damage [19]. With joint laxity, muscle con-
traction then becomes the primary stabilization of the aected joint. Pro-
longed need for dynamic stabilization ultimately leads to fatigue, pain,
and spasm when ligamentous structural support is lacking. This situation
is seen commonly when woodwind players must bear the static load of
the instrument on their thumb and in bass and cello players at the rst
MCP and CMC joints. Treatment is based on improving dynamic stability
with increased muscle tone and endurance. This is best achieved with an oc-
cupational or physical therapist with specic knowledge in performing arts
medicine. In cases in which there is gross instability or frank dislocation, dy-
namic splinting may be needed. In refractory cases, surgical reconstruction
may be indicated. In the case of the thumb, the ulnar collateral ligament of
the rst MCP joint using a palmaris longus graft or plastic reconstruction of
the CMC basal ligament can be used to create a stable functional joint [20].

Trauma
It goes without saying that accidents happen, and musicians are no excep-
tion. Trauma to the upper extremity comes in all forms and can account for
a signicant number of injuries to the instrumentalists. In one series, more
than half of the injuries seen at a performance medicine clinic by an ortho-
pedic surgeon were caused by trauma not associated with playing an instru-
ment [19]. It is impossible to prevent all accidents and possible sources of
trauma, but in a profession that demands precision and excellence beyond
compare, patients must carefully weigh the risks and benets of activities
in which they participate.

Prevention
Ideally, we look to prevent injury and overuse. To completely prevent in-
jury, however, we must know all of the causative factors. As stated previously,
 MUSCULOSKELETAL PROBLEMS IN THE PERFORMING ARTIST 797

the interplay between individual musicians and their instruments combined

with external stressors present an innite number of variables to control
and correct. More research is needed into all areas that aect this group of spe-
cialized patients. Awareness of obvious risk factors and comparative studies in
specialized populations such as athletes, do help us generalize some basic prin-
cipals. Prevention programs, however, no matter what area of medicine, are
riddled with inherent problems. It is a dicult thing to motivate potential
patients when they are feeling well. The constant demand for perfection and
the high anxiety involved with job uncertainty, make this population espe-
cially vulnerable to the play now, pay later attitude. It is our job, together
with music educators to help musicians and in particular young music stu-
dents, to see that preventative strategies are in their best interests for a long
and fullling musical career.

Musculoskeletal injuries in dancers

In great contrast to the long career of musicians are the short physically
demanding and injury-prone years of the dancer. In this chapter we take
a brief look at the most common musculoskeletal injuries encountered by
the dancer and methods of evaluation, treatment, and prevention of injury.
In no other profession is the athlete more predisposed to injury than in
ballet. Typically, professional ballerinas start at the age of 5 to 8 years
and begin an immediate process of tremendous bodily strain. By 30, most
have ended their career. If a female dancer is on track for a professional ca-
reer, she may start dancing sur les pointes, or on toe at age 12. This unnat-
ural position leads to tremendous forces being transmitted to the
metatarsalphalangeal (MTP) and other joints. This and other unusual bio-
mechanical stressors, combined with hypermobility, repetitive motion, de-
layed menarche, secondary amenorrhea, lack of job security, and the
competitiveness of the dance company itself, makes the dancer an athlete
like no other.
To live in the world of the professional ballerina, one must endure hours
of physically demanding practice. The average weekly workload of the
dancer is 45 hours, with only about one fth of that time spent actually per-
forming [21]. The competitiveness of the ballet company breeds an environ-
ment in which admission of injury can mean the end of a career. In this
setting, injuries are reported late or not at all. When the aected part is
then too painful for the dancer to continue, the injury often is at a much
more advanced stage and more dicult to treat. For similar reasons, dancers
may be inclined to return to full participation too soon and risk reinjury.
Ironically, the dancer is the athlete most in need of full pain-free rehabilita-
tion before full return to work. Elite dancers cannot perform at the artistic
level needed without full recovery. Every angle and motion of the classical
ballerina needs to be precise and perfect to convey the complete intention
of the choreographer. Any deviation will be evident to the dancer, dance
798 HANSEN & REED

instructor, and audience but not necessarily the physician. For this reason,
collaboration with instructors, therapists, and treating physicians is vital.

Common patterns of injury/lower extremity

Other chapters in this review detail lower extremity injuries in the dancer.
In this chapter, our only intent is to highlight the unique needs of the dancer
and to emphasize the importance of examining the patient in the context of
her craft. More than 80% of ballet injuries involve the spine and lower ex-
tremities [22]. Looking at the lower extremities, en point dancers, as might
be expected, have a high incidence of foot and ankle injuries. The exagger-
ated metatarsal arch produces bunions, hallux valgus, stiness of the tarsal
joints, and hammer toes. In the early phase of foot pain, modalities such as
heat and ice in combination with rest, elevation, molded arch supports, and
range of motion can alleviate pain. More often, however, injuries are more
serious. Stress fractures are common and present as either focal or diuse
pain initially and then sharp pain in the nal stages. The most common
site for stress fractures in the dancer is the shafts of the 3 central metatarsals,
and stress fractures of the anterior tibial cortex are common in perfor-
mances that require many jumps. Because few stress fractures are evident
on a plain radiograph, radioisotope bone scan done early will help in the di-
agnosis; however, even these have been known to be negative for the rst
few weeks [21].
Other lower limb injuries common to the dancer include ligamentous
strains of the knee and ankle tendonopathies. Tendonitis of the exor hallu-
cis longus tendon at the posterior medial ankle can be especially disabling
with the ankle in maximum dorsiexion as in the plie position. Patellar dis-
locations are also common and are a consequence of the turned out po-
sition. This position puts the knee at a mechanical disadvantage for proper
patellar tracking. Often this acute injury may be missed as the dancer re-
ports to the physician with a painful swollen knee that obscures the patellar
deformity. X-rays must be taken to ensure proper diagnosis and treatment
[23]. Other common injuries include jumpers knee (patellar tendonitis),
muscle strains, meniscal injuries, chondromalacia patellae, and other over-
use injuries related to the excessive training demands [24].

Common spinal injuries

Flexibility is one of the hallmarks of the elite dancer, but it may be one of
their greatest liabilities when it comes to spinal injury. The spine of the
dancer is exposed to tremendous force at a great mechanical disadvantage.
Similar to gymnasts, dancers experience high rates of spondylolysis and
spondylolisthesis [25]. Spondylolysis is a vertebral defect at the pars interar-
ticularis, which is at the junction of the pedicle, transverse process, lamina,
and 2 articular processes. Spondylolisthesis, forward or backward slippage
 MUSCULOSKELETAL PROBLEMS IN THE PERFORMING ARTIST 799

of one vertebral body on the other, may occur owing to pars defect or frac-
tures. Hyperextension, in combination with jumping and heavy lifts, expose
the dancer to increased risk for these injuries. The pars interarticularis is
more vulnerable to trauma in the hyperlordotic and hyperextended position,
and in women, the pars interarticularis is especially at risk. Female dancers
begin their training before the epiphyseal union of this structure, and this
makes spondylolysis more likely [21]. Hypermobility combined with repeti-
tive stress causes microfractures that ultimately lead to stress fractures. This
action puts all of the posterior spinal elements at risk. Stress fractures of the
facet joints are not uncommon and can mimic spondylolysis [26].
Symptoms of spondylolysis include low back pain during strenuous prac-
tice or performance. Pain is localized lateral to midline and is reproduced with
rotation and hyperextension of the lumbar spine. There may be tenderness of
the paravertebral musculature and a positive spinal instability test. Further
workup should include radiographic studies that include AP, lateral, and ob-
lique views of the lumbar spine. If spinal lms are negative, and clinical sus-
picion exists, technetium polyphosphate scan should be done and can
elucidate stress fractures long before standard radiographs [25]. Treatment
of spondylolysis includes relative rest, including a neutral spine-strengthening
program such as Pilates, epidural steroid injections, and aquatic therapy. The
dancer should continue with exibility exercises and activity that does not ag-
gravate symptoms. If there is pain with activities of daily living, bracing may
be necessary. Spondylolisthesis or slippage of the actual vertebral body is
measured in terms of percentage displacement seen on radiograph (Box 1).
Symptoms are similar to those for spondylolysis; however, radicular
symptoms may be apparent if vertebral displacement is marked. Treatment
for grades 1, 2, and asymptomatic grade 3 spondylolisthesis is conservative
and similar to treatment for spondylolysis. Close clinical and radiographic
monitoring is necessary for signs of increasing degree of slippage. For symp-
tomatic grade 3 and above, surgical stabilization is warranted.
Other pain generators in the spine include sacroiliac, discogenic, and
myofascial back pain. Evaluation of these is similar to those in the general
population; however, as stated previously, they are more likely to present
in a more advanced state. Rehabilitation may depend more on looking
for relative strength and exibility decits rather than absolute deciencies.

Box 1. Grading spondylolisthesis

Grade 0: 0% slip
Grade 1: <25% slip
Grade 2: 2550% slip
Grade 3: 5075% slip
Grade 4: 75100% slip
800 HANSEN & REED

Dancers are known for their strong core and extreme exibility, which are
usually the rst targets for physical therapy aimed at generalized low back
pain. Once again, therapists and physicians who can examine the dancer
in context and seek out and correct relative imbalance are more likely to
be successful in long-term management.

Prevention: physical environmental hazards

As is the case in musicians, often the physical environment of the dancer is
outside her control. Great gains have been made in studio oor design and cli-
mate control, but often performances are outside in extreme cold and heat. It
is essential for dancers to properly warm up in conditions of cold temperatures
and stay well hydrated in environments of heat and humidity. Dance oors in
amphitheaters and historical theaters often are of poor quality with respect to
shock absorption. The ideal dance surface is one that absorbs some energy but
is not too springy. Studies done on various highly resilient surfaces have
reported a decrease in musculoskeletal injuries upwards of 80% [27].
Resting when able to avoid overuse and treating injuries early are still
ideas that are dicult to convey to young dancers. These, unfortunately,
are only a few of the methods that are under the direct control of the dancer.
Careful attention to preventative strategies and early treatment will certainly
aid in a pain-free and successful career.

Summary
In this chapter we touched on a wide variety of unique musculoskeletal
conditions in the musician and dancer. We outlined generalized methods
of evaluation that stress the importance of the interdisciplinary approach
in this highly specialized patient population and stressed the importance of
specic involvement of the music or dance instructor in evaluation and man-
agement. We sought to emphasize the need to refer to specialized care early
when in doubt of diagnosis or when usual rst-line treatments fail. We gave
examples of specic injury patterns common in these subgroups and sugges-
tions for early management. Finally, we described some general principals
for prevention of musculoskeletal injury in this group. A physician treating
the performing artist must always keep in mind that in this unique patient
population, their occupation is not only a means of earning a living, it is their
passion. Artists make great sacrice both physically and mentally to bring
the world such immeasurable beauty. It is our responsibility to care for
them in the most comprehensive and compassionate manner possible while
informing them as honestly as possible about their treatment options.

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